Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies.

INTRODUCTION: Across a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. METHODS: We are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews). RESULTS: CHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes. CONCLUSION: Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.

Understanding the risk perception of visceral leishmaniasis exposure and the acceptability of sandfly protection measures among migrant workers in the lowlands of Northwest Ethiopia: a health belief model perspective.

BACKGROUND: Visceral leishmaniasis (VL) is the leading cause of health concerns among Ethiopian migrant workers. Understanding risk perception and health-protective behavior are significant challenges in the prevention and eradication of the disease. As a result, studies are required to assess these important epidemiological factors, which will provide guidance on how to assist migrant workers in taking preventive measures against VL. METHOD: We conducted qualitative research among migrant workers on seasonal agricultural farms in Northwest Ethiopia between June and November 2019 to assess their perception of the risk of contracting VL and their willingness to use protective measures against the disease. Seventeen focus group discussions and 16 key informant interviews were conducted to study migrant workers' risk perception in relation to sandfly bite exposure and use of sandfly control measures. For analysis, all interviews were recorded, transcribed, and translated. ATLASti was used to perform qualitative content analysis on the data. RESULT: Migrant workers are fearful of VL because of previous exposure and the disease's prevalence in the area. They believe, however, that VL is a minor illness that is easily treated. While Insecticide Treated Nets (ITNs) are widely accepted as a protective measure, there are still reservations about using them due to the seasonality of the transmission, difficulties in hanging them on farm areas, and a preference for alternative traditional practices. Regardless of perceived self-efficacy, the central cues were the message delivered by the health workers and an increase in sandfly bite irritation. Based on the findings, three levels of intervention modalities are suggested: 1) increasing pre-arrival awareness through outdoor media (posters, stickers, billboards), 2) encouraging proper use of protective measures upon arrival at farm camps, and 3) informing departing workers on disease recognition and best practices for health-seeking continuous use of protective measures at home. CONCLUSION: This finding suggests that VL prevention interventions should focus on individuals' perceptions in order to promote consistent use of protective measures. The findings are highly useful in planning effective interventions against VL.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial.

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Political connections and psychosocial wellbeing among Women's Development Army leaders in rural amhara, Ethiopia: Towards a holistic understanding of community health workers' socioeconomic status.

Little empirical research exists on the effects of health work on Community Health Workers' (CHWs') social relationships and status, yet these factors are important in understanding the broad social and behavioral drivers and impacts of CHW programs. This is particularly true for unpaid CHWs. Engaging with others as a CHW might help a worker to embody a valued role in society as a selfless, caring individual; or it might strengthen bonds with others and improve social networks and social capital. By combining qualitative, ethnographic, and survey data collected in rural Amhara, Ethiopia from 2013 to 2016, we evaluated the extent to which unpaid female workers in Ethiopia's Women's Development Army (WDA) were better able than their peers to achieve cultural consonance by building desired social connections or fulfilling locally salient models of virtuous womanhood. We conducted a cultural consensus survey (n = 74) and measured cultural consonance in a larger survey of adult women, including WDA leaders (n = 422). We also conducted participant observation and interviews with health officials, local health staff, and WDA leaders. In our study site, WDA leaders were more able than other women to fulfill the cultural ideal of having connections to various government officials. Yet these connections often did not lead to the benefits that WDA leaders hoped for. Also, in contrast to the findings of many other studies, achieving greater cultural consonance was not significantly associated with reduced psychological distress in this population. For women in this rural context, meanwhile, psychological distress is strongly associated with food and water insecurity, stressful life events, and social support. These findings point to the importance of social, economic and psychological support for rural women in Amhara, and specifically for unpaid CHWs.

Does volunteer community health work empower women? Evidence from Ethiopia's Women's Development Army.

Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia's Women's Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands-and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA-that women's empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy-allowed the Ethiopian government and its donors to pursue 'empowerment' without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.

Psychosocial distress among unpaid community health workers in rural Ethiopia: Comparing leaders in Ethiopia's Women's Development Army to their peers.

There is a growing critical social science literature on volunteering in health programs in non-western, low-income countries, yet few have mixed quantitative and qualitative methods to examine the psychological and social wellbeing of unpaid community health workers in such contexts. We address this issue with data from unpaid community health workers (CHWs) and other women who comprise Ethiopia's state-organized Women's Development Army. We draw on qualitative and cross-sectional survey data collected between 2013 and 2016 to test links between various aspects of psychosocial and economic wellbeing and volunteer status in a rural context. We surveyed 422 adult women in Amhara state, 73 of whom were unpaid CHWs in the "Army". We also conducted interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women. Analyses of our qualitative and quantitative datasets show that volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects, and that CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women-especially unmarried women-vulnerable to negative gossip and high levels of psychological distress. To a limited extent, the volunteer CHW position also bolsters married women's subjective socioeconomic status and confidence in achieving future gains in status. By showing that unpaid CHWs do not necessarily enjoy psychosocial benefits, and may experience harm as a result of their work, these findings reinforce the recommendation that CHWs in contexts of poverty be paid and better supported.

Volunteers in Ethiopia's women's development army are more deprived and distressed than their neighbors: cross-sectional survey data from rural Ethiopia.

BACKGROUND: Many Community Health Workers (CHWs) experience the same socioeconomic and health needs as their neighbors, given that they are by definition part of their communities. Yet very few studies aim to measure and characterize experiences of deprivation, poverty, and wellbeing among community health workers. This study quantitatively examines deprivation and wellbeing in Ethiopia's Women's Development Army (WDA), a massive unpaid community health workforce intended to improve population health and modernize the country. METHODS: We conducted a survey of 422 volunteer WDA leaders and community members in rural Amhara state, part of a mixed-methods ethnographic study of the experiences of women in the WDA. The survey asked a variety of questions about respondents' demographics, education, assets, and access to government services. We also used survey measures to evaluate respondents' levels of household food and water security, stressful life events, social support, work burden, and psychological distress. RESULTS: Volunteer WDA leaders and community members alike tend to have very low levels of schooling and household assets, and to be heavily burdened with daily work in several domains. Large proportions are food and water insecure, many are in debt, and many experience stretches of time with no money at all. Our survey also revealed differences between volunteer WDA leaders and other women that warrant attention. Leaders are less likely to be married and more likely to be divorced or separated. Leaders are also more likely to experience some aspects of food insecurity and report greater levels of psychological distress and more stressful life events. They also report slightly less social support than other women. CONCLUSIONS: In rural Amhara, women who seek out and/or are sought and recruited for leader roles in the WDA are a population living in precarity. In several domains, they experience even more hardship than their neighbors. These findings highlight a need for careful attention and further research into processes of volunteer CHW selection, and to determine whether or not volunteering for CHW programs increases socioeconomic and health risks among volunteers. CHW programs in settings of poverty should stop using unpaid labor and seek to create more paid CHW jobs.

Governance and functionality of community water schemes in rural Ethiopia.

OBJECTIVES: A key challenge for achieving universal water access in Sub-Saharan Africa is poor sustainability of water schemes. Previous studies have posited factors that may lead to failed schemes; however, empirical data are lacking. METHODS: We conducted direct observations of water sources and interviewed water committee members about governance in two regions of Ethiopia. Based on direct observation at each water point, and harmonizing previous research in the sector, we developed an ordinal measure of functionality. Among functional systems, linear regression models were used to assess changes in score or level of functionality against governance characteristics. RESULTS: Of 89 water schemes over 5 years old, 82 had sufficient data to receive a score. Higher functionality scores were associated with having good records, meeting regularly, financial audits, higher monthly fees, a paid caretaker and water committees with capacity to perform minor repairs. CONCLUSIONS: Our continuous measure of functionality was simple to derive, objective and may be widely applicable for further studies assessing key indicators of sustainability.

Physical condition of Olyset® nets after five years of utilization in rural western Kenya.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are a cornerstone of malaria control at present, and millions are used each day across the globe. However, there is limited information about the durability of LLINs under different conditions of utilization and there is no consensus about when a LLIN ceases to be protective due to physical deterioration. This knowledge is important for malaria control programmes to plan for procurement and replacement. METHODS: A cross-sectional survey of 208 households where Olyset® nets distributed five years ago were still present was conducted in the village of Sauri, western Kenya, in the context of the Millennium Villages Project. Information on bed net utilization and maintenance was collected in each household through a structured questionnaire, and one five-year-old Olyset® net from each sampled household was randomly selected and collected for physical examination. All holes larger than 0.5 cm were measured in each net, registering their position, and a hole index was calculated following WHO guidelines. Nets were classified as in good condition, moderately damaged or badly torn based on the hole index. The analysis explored the associations between demographic and socioeconomic characteristics of households, patterns of bed net utilization and maintenance and physical condition of the nets. Additional analysis was conducted using malaria prevalence data collected in a separate survey to explore if there was any association between the condition of the net collected in a household and the presence of malaria parasites in members of that household. RESULTS: 81.4% of Olyset® nets distributed five years ago were still present in the surveyed households, and 98.97% of the nets were reportedly used the previous night. Nets had an average of 34.2 holes (95% CI 30.12-38.22), and the mean hole index was 849 (95% CI 711-986), IQR 174-1,135. 15.2% of nets were still in good condition, 46.1% were moderately damaged and 38.7% were badly torn after five years of utilization. There was no association between household characteristics or patterns of bed net utilization or maintenance and physical condition of the nets. The only predictor of the physical condition of the net was the cleanliness at the time of examination. There was a difference of 17.6 percentage points in the proportion of households with at least one blood smear positive for Plasmodium falciparum between households with a net in good condition (5.3%) and those with a moderately damaged or badly torn net (22.9%), 95% CI (0.04-0.305), t=2.77 with unequal variance, p=0.009. CONCLUSIONS: Olyset® nets were used extensively in Sauri, western Kenya after five years of distribution, regardless of their physical condition. However, only 15% were found in good condition. Nets in good condition seem to be still protective after five years of utilization, while nets with more than 100 cm2 of holed surface may be associated with higher malaria parasitaemia at household level. Continued replacement of damaged nets and promotion of net maintenance and repair may be necessary to maintain the protective effectiveness of LLINs.

Water insecurity in 3 dimensions: an anthropological perspective on water and women's psychosocial distress in Ethiopia.

Water insecurity is a primary underlying determinant of global health disparities. While public health research on water insecurity has focused mainly on two dimensions, water access and adequacy, an anthropological perspective highlights the cultural or lifestyle dimension of water insecurity, and its implications for access/adequacy and for the phenomenology of water insecurity. Recent work in Bolivia has shown that scores on a water insecurity scale derived from ethnographic observations are associated with emotional distress. We extend this line of research by assessing the utility of a locally developed water insecurity scale, compared with standard measures of water access and adequacy, in predicting women's psychosocial distress in Ethiopia. In 2009-2010 we conducted two phases of research. Phase I was mainly qualitative and designed to identify locally relevant experiences of water insecurity, and Phase II used a quantitative survey to test the association between women's reported water insecurity and the Falk Self-Reporting Questionnaire (SRQ-F), a measure of psychosocial distress. In multiple regression models controlling for food insecurity and reported quantity of water used, women's water insecurity scores were significantly associated with psychosocial distress. Including controls for time required to collect water and whether water sources were protected did not further predict psychosocial distress. This approach highlights the social dimension of water insecurity, and may be useful for informing and evaluating interventions to improve water supplies.

Food insecurity among volunteer AIDS caregivers in Addis Ababa, Ethiopia was highly prevalent but buffered from the 2008 food crisis.

Our objective in this study was to assess the validity and dependability of the Household Food Insecurity Access Scale (HFIAS), which was developed for international use, among community health volunteers in Addis Ababa, Ethiopia. The HFIAS was translated into Amharic and subsequently tested for content and face validity. This was followed by a quantitative validation study based on a representative sample (n = 99) of female community volunteers (HIV/AIDS home-based caregivers), with whom the HFIAS was administered at 3 time points over the course of 2008, in the context of the local and global "food crisis." By pooling observations across data collection rounds and accounting for intra-individual correlation in repeated measures, we found that the HFIAS performed well according to standards in the field. We also observed slight amelioration in reported food insecurity (FI) status over time, which seems paradoxical given the increasing inaccessibility of food over the same time period due to inflating prices and disappearing food aid. We attempted to resolve this paradox by appealing to self-report-related phenomena that arise in the context of longitudinal study designs: 1) observation bias, in which respondents change their reports according to changing expectations of the observer-respondent relationship or change their behavior in ways that ameliorate FI after baseline self-reports; and 2) "response shift," in which respondents change their reports according to reassessment of internal standards of FI. Our results are important for the validation of FI tools and for the sustainability of community health programs reliant on volunteerism in sub-Saharan Africa.